Global perspective of familial hypercholesterolaemia: a cross-sectional study from the EAS Familial Hypercholesterolaemia Studies Collaboration (FHSC)

BACKGROUND

The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally.

METHODS

Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases.

FINDINGS

Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53·6%] women) from 56 countries were included in the study. Of these, 31 798 (75·4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84·2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46·2 years (IQR 34·3-58·0); median age at diagnosis of familial hypercholesterolaemia was 44·4 years (32·5-56·5), with 40·2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17·4% (2·1% for stroke and 5·2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81·1%) were receiving statins and 3691 (21·2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5·43 mmol/L (IQR 4·32-6·72) among patients not taking lipid-lowering medications and 4·23 mmol/L (3·20-5·66) among those taking them. Among patients taking lipid-lowering medications, 2·7% had LDL cholesterol lower than 1·8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1·8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p<0·001).

INTERPRETATION

Familial hypercholesterolaemia is diagnosed late. Guideline-recommended LDL cholesterol concentrations are infrequently achieved with single-drug therapy. Cardiovascular risk factors and presence of coronary disease were lower among non-index cases, who were diagnosed earlier. Earlier detection and greater use of combination therapies are required to reduce the global burden of familial hypercholesterolaemia.

FUNDING

Pfizer, Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron.

What have we learned from Turkish familial hypercholesterolemia registries (A-HIT1 and A-HIT2)?

BACKGROUND AND AIMS

Familial hypercholesterolemia (FH) is a common genetic disease of high-level cholesterol leading to premature atherosclerosis. One of the key aspects to overcome FH burden is the generation of large-scale reliable data in terms of registries. This manuscript underlines the important results of nation-wide Turkish FH registries (A-HIT1 and A-HIT2).

METHODS

A-HIT1 is a survey of homozygous FH patients undergoing low density lipoprotein (LDL) apheresis (LA). A-HIT2 is a registry of adult FH patients (homozygous and heterozygous) admitted to outpatient clinics. Both registries used clinical diagnosis of FH.

RESULTS

A-HIT1 evaluated 88 patients (27 ± 11 years, 41 women) in 19 centers. All patients were receiving regular LA. There was a 7.37 ± 7.1-year delay between diagnosis and initiation of LA. LDL-cholesterol levels reached the target only in 5 cases. Mean frequency of apheresis sessions was 19 ± 13 days. None of the centers had a standardized approach for LA. Mean frequency of apheresis sessions was every 19 ± 13 (7-90) days. Only 2 centers were aware of the target LDL levels. A-HIT2 enrolled 1071 FH patients (53 ± 8 years, 606 women) from 31 outpatients clinics specialized in cardiology (27), internal medicine (1), and endocrinology (3); 96.4% were heterozygous. 459 patients were on statin treatment. LDL targets were attained in 23 patients (2.1% of the whole population, 5% receiving statin) on treatment. However, 66% of statin-receiving patients were on intense doses of statins. Awareness of FH was 9.5% in the whole patient population.

CONCLUSIONS

The first nationwide FH registries revealed that FH is still undertreated even in specialized centers in Turkey. Additional effective treatment regiments are urgently needed.

Patient characteristics and statin discontinuation-related factors during treatment of hypercholesterolemia: an observational non-interventional study in patients with statin discontinuation (STAY study)

OBJECTIVE

The purpose of this study was to identify patient characteristics and statin discontinuation-related factors in patients with hypercholesterolemia.

METHODS

A total of 532 patients (age mean±SD: 57.4±11.5 years; 52.4% women, 47.6% men) with hypercholesterolemia and statin discontinuation were included in this national cross-sectional non-interventional observational study. Data on socio-demographic characteristics of patients, cardiovascular risk factors, past treatment with and discontinuation of statin treatment were collected in one visit.

RESULTS

Mean±SD duration of hypercholesterolemia was 4.9±4.2 years at time of discontinuation of statin treatment. Statin treatment was initiated by cardiologists in the majority of cases (55.8%), whereas discontinuation of statin treatment was decided by patients in the majority of cases (73.7%), with patients with higher (at least secondary education, 80.4%) more likely than those with lower (only primary education, 69.7%) to decide to discontinue treatment (p=0.022). Negative information about statin treatment disseminated by TV programs-mostly regarding coverage of hepatic (38.0%), renal (33.8%), and muscular (32.9%) side effects (32.9%)-was the most common reason for treatment discontinuation.

CONCLUSION

The decision to discontinue statin treatment was made at the patient's discretion in 74% of cases, with higher likelihood of patients with higher educational status deciding to discontinue treatment and switch to non-drug lipid-lowering alternatives. Cardiologists were the physicians most frequently responsible for the initiation of the statin treatment; coverage of several non-life-threatening statin side effects by TV programs and patients' lack of information regarding high cholesterol and related risks were the leading factors predisposing to treatment discontinuation.

Correlation between N-terminal pro B-natriuretic peptide and ultrasonic backscatter: implications for diastolic dysfunction in hypertension

OBJECTIVE

This study was designed to determine how N-terminal pro brain-natriuretic peptide (NT-proBNP) levels correlate with cyclic variation of integrated backscatter (CVIBS) as a reflection of abnormal diastolic function in hypertension.

PATIENTS

Forty essentially hypertensive patients were studied. CVIBS values were obtained from the septal wall in the parasternal long-axis view. Twelve had normal diastolic function, 18 had impaired relaxation, and 10 had pseudonormal pattern.

RESULTS

Patients with normal diastolic function had a mean NT-proBNP concentration of 34 +/- 17 pg/ml and a mean CVIBS value of 7.1 +/- 0.9 dB; those with impaired relaxation had a mean NT-proBNP concentration of 71 +/- 25 pg/ml and a mean CVIBS value of 6.7 +/- 1.1 dB. Patients with pseudonormal pattern had the highest NT proBNP levels (206 +/- 75 pg/ml) and lowest CVIBS values (5.7 +/- 0.9 dB). An NT-proBNP value of 62 pg/ml had a sensitivity of 83% and a specificity of 91%; a CVIBS value of 7.2 dB had a sensitivity of 83.3% and a specificity of 66.7% for detecting diastolic dysfunction. An NT-proBNP value of 120 pg/ml had a sensitivity of 76% and a specificity of 96%; a CVIBS value of 6.1 dB had a sensitivity of 87.5% and a specificity of 75% for detecting severe diastolic dysfunction. A close correlation was found between the NT-proBNP and CVIBS values (r: 0.54, P < 0.05).

CONCLUSION

Combinative use of NT-proBNP and CVIBS can detect the presence of diastolic abnormalities on echocardiography. A good correlation was found between the NT-proBNP and CVIBS values in detecting diastolic dysfunction in essentially hypertensive patients.

The role of N terminal pro-brain natriuretic peptide in the evaluation of left ventricular diastolic dysfunction: correlation with echocardiographic indexes in hypertensive patients

The utility of N-Terminal pro Brain Natriuretic Peptide (NT-proBNP) and Brain Natriuretic Peptide (BNP) for detecting left ventricular (LV) diastolic dysfunction in hypertensive patients without heart failure symptoms is unclear. In this study, we investigated the relation between NT-proBNP plasma levels and LV diastolic dysfunction in hypertensive patients without systolic dysfunction.

METHOD

We studied 40 ambulatory patients (26 women, mean age 52 +/- 5) with controlled hypertension. LV diastolic function was assessed with conventional Doppler, by means of mitral inflow and with tissue Doppler echocardiography by means of mitral annulus. The ratio of early diastolic transmitral E wave velocities to tissue Doppler mitral annulus early diastolic E' wave velocities (E/E'), was used to detect LV filling pressures. Patients were divided in three groups according to E/E' ratios < 10 (group I), E/E' ratios ''between'' 10 and 15 (group II) and E/E' ratios > 15 (group III). Plasma concentrations of NT-proBNP were measured by electro chemiluminescence's immunoassay.

RESULTS

The NT-proBNP blood levels were positively correlated significantly with E/E' ratio (r = 0.80, P < 0.0001). Patients with elevated LV end diastolic pressure (LVEDP), defined as E/E' > 15 (n = 8) had highest NT-proBNP (203 +/- 75 pg/ml) levels. E/E' 10 to 15 group (n = 16) had a mean NT-proBNP level of 71 +/- 26 pg/ml, and those with E/E' < 10 (n = 16) had 39 +/- 20 pg/ml. A NT-proBNP value of 119 pg/ml had a sensitivity of 87%, a specificity of 100% for predicting E/E' > 15.

CONCLUSION

The assessment of the blood concentration of NT-proBNP is of potential value for identification of those patients with hypertension to detect early cardiovascular changes, especially LV diastolic dysfunction.

Primary percutaneous coronary intervention of anomalous origin of right coronary artery above the left sinus of Valsalva in a case with acute myocardial infarction. Coronary anomalies and myocardial infarction

Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is exceedingly rare. We presented a case with anomalous origin of the RCA above the left sinus of Valsalva with inferior wall myocardial infarction and successful primary percutaneous coronary intervention to this artery which is the first report in the literature.

Ultrasound Tissue Characterization by Integrated Backscatter for Analyzing Fluorouracil Induced Myocardial Damage

BACKGROUND

5-Fluorouracil (5-FU) cardiotoxicity is a well-known clinical phenomenon whose pathophysiology remains controversial. Cyclic variation of integrated backscatter (CVIBS) assesses acoustic properties of myocardium that may reflect both contractility and structural changes. The aim of this study was to evaluate CVIBS alterations in cancer patients under high-dose leucovorin and infusional 5-FU (HDLV5FU) chemotherapy.

METHOD

We prospectively evaluated 37 cancer patients under HDLV5FU treatment. Transthoracic echocardiography and CVIBS were performed at the 0th, 48th hours, and on day 15 of the first cycle. The parasternal long-axis view was preferred to obtain the image of integrated backscatter and mainly two regions of interest--interventricular septum (IVS) and posterior wall (PW)--were used.

RESULTS

Clinical cardiotoxicity was observed in two patients. No significant differences were detected in pre- and posttreatment conventional echocardiography evaluations. However, both the IVS (9.3 +/- 1.0 to 8.1 +/- 1.2 dB, P < 0.001) and PW (9.1 +/- 0.7 to 7.8 +/- 0.9 dB, P < 0.001) CVIBS values significantly decreased in all patients. All values were returned to pretreatment levels (9.2 +/- 0.9 dB in the CVIBS-IVS and 8.9 +/- 0.6 dB in CVIBS-PW, respectively) on day 15 after the treatments.

CONCLUSION

This study suggests that HDLV5FU may cause acute transient alterations in CVIBS values in the absence of clinical symptoms and signs of cardiotoxicity. The clinical value of CVIBS should be further studied in patients receiving 5-FU-based therapy.

Influence of high-dose leucovorin and 5-fluorouracil chemotherapy regimen on P wave duration and dispersion

BACKGROUND

Although 5-fluorouracil (5-FU)-related cardiotoxicity is well known, atrial arrhythmia, as a potentially serious complication has not been studied in detail. The aim of this study was to determine the P max and Pd in the electrocardiograms (ECG) of patients receiving 5-FU treatment.

METHODS

Twenty-five patients (mean age: 62 years) receiving a 5-FU bolus plus continuous infusion with calcium leucovorin over 48 h and with normal pre-treatment cardiac physical examinations, ECG and echocardiography were enrolled. P maximum (P max), P minimum (P min) and P dispersion (Pd) (maximum minus minimum P wave duration) were measured from the 12-lead ECG at the 0th and 48th hour of the first chemotherapy cycle. Echocardiography was also obtained in all patients at the same times.

RESULTS

Clinical cardiotoxicity was observed in two patients. P max and Pd were both significantly longer after 5-FU treatment at the 48th hour (P < 0.001). P min did not change (P > 0.05).

CONCLUSION

Treatment with 5-FU based regimens may increase Pd and prolong the P max in cancer patients. These alterations may be predictive of patients at risk of atrial arrhythmias during 5-FU treatment.

Microalbuminuria Is Associated with Reduced Cardiac Cyclic Variation of Integrated Backscatter Signal in Severe Hypertension

OBJECTIVE

Microalbuminuria (MA) as a marker of systemic vascular disease and left ventricular (LV) hypertrophy is associated with increased cardiovascular mortality and morbidity in patients with essential hypertension. The aim of this study was to investigate changes in cardiac cycle-dependent variation of integrated backscatter signals (CVIBS) in hypertensive patients with MA.

METHODS

Randomly selected 60 hypertensive patients (mean age 51 +/- 8) with uncontrolled blood pressure (BP) (>/=130 mmHg systolic and/or 85 mmHg diastolic) were included. All patients underwent urinary albumin excretion (UAE) measurements, 24-hour ambulatory BP monitoring, and LV echocardiographic examination. UAE was measured in two separate 24-hour urine collection and mean of two values was taken into consideration. Normotensive 20 healthy subjects served as controls. CVIBS values were obtained from mid-anteroseptal, mid-posterolateral, and mid-inferior areas at the papillary muscle level in the parasternal short-axis view. CVIBS was defined as the difference in integrated backscatter values between systole and diastole. CVIBS values in MA positive patients were compared with the values in MA negative patients and control subjects.

RESULTS

Twelve patients had MA (UAE 30 to 300 mg/day) while 48 patients had normal UAE (<30 mg/day). The wall thickness (at septum and posterior) and left ventricular mass index (LVMI) values were all significantly higher in hypertensive patients with MA (P < 0.01). The CVIBS values in MA positive group were significantly lower than the CVIBS values both in MA negative hypertensive patients and control subjects (P < 0.01).

CONCLUSION

This study demonstrates that in hypertensive patients a high LVMI is associated with reduced CVIBS values and MA appears to be a marker of hypertrophy.

A New Perspective on Cardiotoxicity of 5-Fluorouracil

BACKGROUND

The pathophysiology of 5-fluorouracil (5-FU) cardiotoxicity is still controversial. The objective of this study was to assess the influence of high-dose leucovorin and infusional 5-FU regimen (HDLV5FU) on cardiac tissues.

METHODS

We monitored 28 patients (median age 68 years) under HDLV5FU chemotherapy with complete blood counts, cardiac enzymes, C-reactive protein, coagulation tests, Holter electrocardiogram, and conventional echocardiography. Cardiac ultrasonic tissue characterization with integrated backscatter (IBS) analysis was performed in the 16 last enrolled patients.

RESULTS

The magnitude of both anterior and posterior cardiac IBS values significantly decreased at the 48th hour of treatment compared to both 0th hour and day 15 (p < 0.003). Cardiac IBS values on the 15th day were not different from the 0th hour. Clinical cardiotoxicity was not observed and other monitored parameters did not change significantly in any patient (p > 0.5 for all).

CONCLUSION

Cardiac IBS analysis suggests that 5-FU might cause reversible subclinical myocardial dysfunction.

The effect of atorvastatin on platelet function in patients with coronary artery disease

BACKGROUND

Lipid-lowering therapy was shown to have several beneficial effects in patients with coronary artery disease (CAD).

AIM

The objective of this study was to investigate the effect of atorvastatin on platelet aggregation in patients with CAD.

METHODS

Twenty-five hypercholesterolaemic patients who had angiographically proven CAD and 16 normal subjects were enrolled. All patients received 10 mg/day atorvastatin for two months. Anti-platelet agents were discontinued 15 days prior to blood sampling at the beginning and at the end of the atorvastatin therapy. Aggregometric curves of the platelets in response to ADP, collagen and epinephrine were obtained using the aggregometry (turbidimetric) technique.

RESULTS

In patients with CAD, total cholesterol (TC) and LDL cholesterol (LDL-C) basal levels were measured (230 +/- 49 mg/dl, 140 +/- 41 mg/dl, respectively). Following lipid-lowering therapy, TC and LDL-C decreased significantly (p < 0.05). The activation measurements of aggregometric curves decreased significantly compared with basal parameters in response to ADP but not in response to collagen and epinephrine.

CONCLUSION

Lipid-lowering therapy with the HMG-CoA reductase inhibitor, atorvastatin, had a marked reduction effect on platelet aggregation.

Cardiac cyclic variation of integrated backscatter in hypertension and dialysis patients

BACKGROUND

Cyclic variation of myocardial-integrated backscatter (CV-IB) offers a non-invasive myocardial contractile performance assessment. There is limited data concerning CV-IB in end-stage renal disease (ESRD) patients.

METHODS

Forty essential hypertensive (EH) patients (mean age 51+/-8 yrs) and 24 ESRD patients (mean age 49+/-14 yrs) were compared to 10 healthy controls (mean age 45+/-10 yrs). A 2D-Doppler echocardiography with digitized imaging was performed to characterize myocardial ultrasonic tissue by CV-IB between systole and diastole at the interventricular septum (IVS) and left ventricular (LV) posterior wall (PW).

RESULTS

There was no significant difference between age and sex among groups. Systolic and diastolic blood pressures (BP) were both higher in EH patients (157/96 mmHg in EH, 129/81 mmHg in ESRD and 115/77 mmHg in controls, p<0.001). Left ventricular mass index (LVMI) was higher in EH and ESRD patients than in controls (respectively, 119+/-37, 130+/-46, 87+/-12 g/m2, p<0.05), while there was no significant difference found between EH and ESRD patients. EH patient CV-IB values were significantly lower than in ESRD patients and controls (respectively, 6.9+/-1.6, 8.6+/-0.7, 10.6+/-1.1 dB, p<0.001 for IVS, 7.7+/-1.3, 8.7+/-0.8, 10.4+/-1.1 dB, p<0.001 for PW). CV-IB for PW and IVS were significantly lower in ESRD patients than in controls (p<0.001).

CONCLUSIONS

CV-IB can offer useful parameters for myocardial structure in EH and ESRD patients. Further studies are needed to clarify CV-IB in ESRD patients.

The effect of heart rate on color M-mode Doppler flow propagation velocity and continuous-wave Doppler parameters in aortic insufficiency

BACKGROUND AND AIM OF THE STUDY

The results of previous studies have suggested that an increase in heart rate (HR) may have a beneficial effect on the hemodynamic condition of patients with aortic regurgitation (AR), and reduce AR severity. An increase in HR was shown to cause a significant increase in regurgitant slope and to significantly shorten the pressure half-time (PHT), both of which are considered to be signs of worsening regurgitation. Color M-mode Doppler flow propagation velocity (FPV) was used to assess AR severity, but no data were available regarding the effects of HR on FPV measurement of AR. The study aim was to evaluate the effect of HR on FPV, and to compare FPV and continuous-wave (CW) Doppler parameter (PHT and slope) variations resulting from an increase in HR.

METHODS

Sixty-eight patients (28 males, 40 females; mean age 52 +/- 15 years) with AR of various severity were included. Color M-mode Doppler was used in FPV, while CW Doppler was used in PHT and slope measurements. Atropine sulfate was titrated in all patients to achieve at least a 20% increase in HR. The FPV, PHT, slope and regurgitant fraction (RF) of AR were measured before and after the increase in HR.

RESULTS

An increase in HR (77.8 +/- 8.9 versus 103 +/- 9.9 bpm; p < 0.001) caused a decrease in color M-mode Doppler FPV (51 +/- 21 versus 44 +/- 19 cm/s), in the PHT of the regurgitant velocity curve (468 +/- 154 versus 411 +/- 128 ms), and in the RF of the AR (30.2 +/- 16.3 versus 26.1 +/- 14%). The slope of the regurgitant velocity was increased (291 +/- 136 versus 358 +/- 122 cm/s2). All of these variations were statistically significant.

CONCLUSION

An increase in HR caused a decrease in the FPV and RF of the aortic regurgitation, and both changes were signs of improved regurgitation. FPV appears to be a more valuable parameter than CW Doppler parameters in determining improvements in AR resulting from an increase in HR.

Novel approach to measure myocardial performance index: pulsed-wave tissue Doppler echocardiography

A simple, reproducible, noninvasive myocardial performance index (MPI) for the assessment of overall cardiac function has been described previously. The purpose of this study was to compare the MPI obtained by pulse Doppler method with the MPI obtained by tissue Doppler echocardiography (TDE) in normal subjects and patients with dilated cardiomyopathy (DCMP). Fifteen patients with DCMP and 15 healthy subjects were included. In order to calculate MPI by TDE, isovolumetric contraction (IVCT), relaxation time (IVRT), and ejection time (ET) were measured at two different sites of mitral annulus: septum and lateral. MPI was calculated by dividing the sum of IVCT and IVRT by ET at each site of measurement. The mean MPI value was found by dividing the sum of these MPI values into two. The same parameters were measured using the mitral inflow and left ventricular outflow velocity time intervals in pulsed Doppler method. At all sites measured, MPI by TDE correlated well with conventional MPI both in healthy subjects and patients with DCMP. The highest correlation was observed in mean values of MPI by TDE:r = 0.94, P < 0.0001in healthy subjects; andr = 0.95, P < 0.0001in patients with DCMP. In conclusion, this study clearly demonstrated that MPI could be measured by TDE and it correlated well with conventional MPI in normal and diseased heart.

Cyclic variation of myocardial integrated backscatter and myocardial wall thickness during percutaneous coronary angioplasty

Cyclic variation of myocardial integrated backscatter (CVIBS) and change in myocardial wall thickness (WT%) were evaluated during percutaneous transluminal coronary angioplasty (PTCA). Fourteen patients who underwent PTCA of the proximal left anterior descending (LAD) coronary artery were included in the study. PTCA was performed by inflating the balloon at the site of the LAD lesion for 1 minute. CVIBS was measured at three episodes during PTCA in the parasternal short-axis view: before the inflation, at the end of 1-minute inflation, and at the fifth-minute after deflation of the balloon. Three regions of interest were used to evaluate the three-vessel territories: mid-anteroseptal area for LAD, mid-posterolateral area for circumflex artery, and mid-inferior area for right coronary artery. The WT% was calculated in each area. In the LAD territory, CVIBS measured at the end of 1-minute inflation was lower than the values obtained before PTCA, 5.2 +/- 1.0 decibel (dB) versus 3.7 +/- 0.7 dB (P < 0.01). CVIBS magnitudes increased at the fifth-minute after the deflation back up even to higher levels than pre-PTCA values,6.1 +/- 1.0 dB versus 5.2 +/- 1.0 dB (P < 0.01). The WT% values decreased during balloon inflation but did not recover to the pre-inflation values measured at fifth-minute after deflation. In other sites, there was no change in either CVIBS or WT% values at any time studied. The observed increase in CVIBS may be an indicator of restoration of blood flow to ischemic myocardium.

Value of measuring myocardial performance index by tissue Doppler echocardiography in normal and diseased heart

Myocardial performance index (MPI) is a simple and reproducible method for the assessment of overall cardiac function. In this study, we evaluated the applicability and usefulness of pulsed-wave tissue Doppler echocardiography (TDE) as a tool to calculate MPI in comparision with a conventional Doppler method. Twenty-five patients with previous myocardial infarction (MI) and 15 healthy subjects were included. In order to calculate MPI by TDE, isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT), and ejection time (ET) were measured at four different sites in the mitral annulus: septum, lateral, anterior, and inferior. MPI was calculated by dividing the sum of IVCT and IVRT by ET at each site of measurement. The mean MPI value was found by dividing the sum of these MPI values into four. The same parameters were measured using the mitral inflow and left ventricular outflow velocity time intervals by a conventional method. MPI by TDE correlated well with conventional MPI in healthy subjects (r = 0.81, P < 0.0001). Although it continued to be statistically significant, the correlation between the two methods of measuring MPI, TDE and conventional, in patients with previous MI was not as high as it was in healthy individuals (P < 0.001, r = 0.62). This is due to the lesser degree of correlation between IVRT and IVCT values obtained by TDE and the conventional method (r = 0.49, P < 0.05; r = 0.56, P < 0.05; respectively). In conclusion, this study has demonstrated that MPI could be measured by tissue Doppler and that it correlated well with conventional MPI. Moreover, MPI by TDE has the advantage of assessing both regional and global myocardial performance.

Transient ischemic attack with apical hypertrophic cardiomyopathy

A 66-year-old Turkish male patient admitted to our emergency department with a transient ischemic attack (TIA) is described. Transthoracic echocardiography revealed apical hypertrophic cardiomyopathy (HCM) and an ECG sinus rhythm. Transesophageal echocardiography detected severe spontaneous echocontrast (SEC) in the left atrial (LA) cavity with apical hypertrophy.

A new echocardiographic method for the assessment of the severity of aortic regurgitation: color M-mode flow propagation velocity

PURPOSE

Echocardiographic Doppler methods widely used in assessment of the severity of aortic regurgitation (AR) are considered sensitive and reliable. However, they all have limitations for quantitation of AR. The color M-mode Doppler flow propagation velocity (FPV) method has been shown to provide useful insights in the evaluation of left ventricular diastolic function and appears to be minimally affected with preload changes. Clinical data regarding the value of FPV in the determination of the significance of valvular insuffiencies are lacking. The purpose of this study was to evaluate the use of FPV in measurement of the severity of AR and to compare its reliability with angiography and other echocardiographic methods.

METHODS

Twenty-nine patients (13 male, 16 female) who had cardiac catheterization for various reasons before echocardiographic evaluation were included. The mean age was 53.6 +/- 13.4 years. At the time of cardiac catheterization, the degree of AR was assessed as mild in 10 patients, as moderate in 12, and as severe in 7. In all patients, FPV measurements of AR were obtained with color M-mode Doppler in the apical 5-chamber view. Regurgitation jet height and its ratio to left ventricular outflow obtained in the parasternal long axis with color flow Doppler, pressure half-time, and slope of AR obtained with continuous wave Doppler in apical 5-chamber view were other echocardiographic methods chosen for comparison.

RESULTS

The mean values of FPV were 93.1 +/- 18.4 cm/s, 49.8 +/- 8.0 cm/s, and 31.7 +/- 4.9 cm/s in severe, moderate, and mild AR groups, respectively (P <.001). Significant correlation was observed between angiographic grades, FPV, pressure half-time, slope, and jet height and ratio to left ventricular outflow (P <.0001, r = 0.93; P <.0001, r = -0.81; P <.0001, r = 0.76; P <.0001, r = 0.92, respectively).

CONCLUSION

FPV is a simple, practical, and reliable method for the quantification of AR.

Severe aortic and mitral calcification in identical twin boys

Identical twin boys presented with exercise-induced syncope. Echocardiographic examination revealed severe calcification at aortic valves, mitral anterior leaflets, and mitral annuli in both patients. In addition, basal interventricular septum was also involved in 1 patient. Doppler evaluation demonstrated severe aortic stenosis with a peak gradient of 112 and 118 mm Hg in both patients. Moderate mitral stenosis was also detected in one of them. Patients underwent operation for valve replacement.

Transthoracic echocardiographic documentation of disappearance of massive pulmonary artery thromboemboli after fibrinolytic therapy

In this paper, we report two cases of acute massive pulmonary thromboemboli with pulmonary artery thrombus, in which disappearance of thrombus followed fibrinolytic therapy were documented at transthoracic echocardiographic follow-up. Data from these limited experiences suggest that, transthoracic echocardiography might be useful as a first diagnostic screening in cases of suspect pulmonary thromboembolism and thrombolytic therapy might be considered in patients with pulmonary artery thrombus with pulmonary embolism.

Cardiovascular involvement in Behçet's disease

The incidence and nature of cardiac involvement in Behçet's disease are not yet clearly documented. We first used transesophageal echocardiography in combination with resting and signal averaged electrocardiography to define cardiac involvement in Behçet's patients. Transthoracic and multiplane transesophageal echocardiography, and resting and signal averaged electrocardiography were performed in 35 Behçet's disease patients (9 women and 26 men, mean age: 38 +/- 12 years) and 30 normal subjects. Higher incidences of interatrial septum aneurysm (31% to 6%), mitral valve prolapse (25% to 3%), mitral regurgitation (40% to 6%) and aneurysmal dilatations of sinus valsalva and ascendan aorta were observed in the Behçet's disease patients than in the normal subjects. Mean QT dispersion and mean corrected QT dispersion values were significantly greater in the patients with Behçet's disease. Patients with interatrial septum aneurysm (and/or PFO), valvular dysfunction or proximal aorta dilatation had greater QT dispersion values than thase without these pathologies in the Behçet's group (63 +/- 11 vs 44 +/- 19 ms, 58 +/- 23 vs 41 +/- 24 and 60 +/- 27 vs 42 +/- 23 ms respectively, P<0.05). Positive signal averaged electrocardiography parameters were detected in 18 (51%) Behçet's disease patients compared with one (3%) in controls (P<0.001). Dilatation of the proximal aorta, interatrial septal aneurysm, mitral valve prolapse, and mitral regurgitation are the common findings of cardiac involvement in Behçet's disease. Increased dispersion of ventricular repolarisation and positive late potentials are also detected. QT dispersion is significantly higher in patients with these cardiac abnormalities. These findings suggest that cardiac involvement in this disorder is a diffuse process which involves both cardiac structure and vascular elements.

[The relationship of the left atrial spontaneous echo contrast integrated backscatter with left atrial appendix function and tissue doppler characteristics]

OBJECTIVE

Integrated backscatter (IBS) is an objective method to measure spontaneous echo contrast (SEC) quantitatively. The purpose of this study was to investigate the relationship between the quantitative values of left atrial SEC measured by using IBS with its qualitative gradation as well as the left atrial appendix (LAA) functions and LAA tissue Doppler characteristics (TD).

METHODS

Thirty-two patients (23 female, 9 male) with various diseases undergoing transesophageal echocardiography (TEE) were included. Mean age was 52 + 13 years. Left atrial SEC was graded as no SEC (n = 12), mild (n = 12) or severe SEC (n = 8) in patients underwent TEE. LAA peak emptying and LAA apical and basal TD velocities were measured. LAA ejection fraction was assessed by standard means.

RESULTS

Between no SEC and mild SEC groups, left atrium IBS and LAA apical TD values were found statistically significant. But there were no differences between two groups regarding LAA emptying velocities, LAA ejection fraction values and LAA basal TD values. All of these parameters were found statistically different between severe and mild SEC groups. The left atrial IBS values were found to be correlated positively with the qualitative SEC grade. The left atrial IBS values correlated negatively with LAA emptying, apical TD velocities and LAA ejection fraction values.

CONCLUSION

Integrated backscatter provides an objective quantitative measure of SEC that correlates well with LAA apical TD velocities and the other parameters of LAA.

[Effects of metoprolol on the signal averaged electrocardiogram and QT dispersion in acute myocardial infarction]

OBJECTIVE

The determination of high risk patients for sudden death and sustained ventricular tachycardia after acute myocardial infarction constitutes the main goal to decrease morbidity and mortality. Every attempt that decreases the frequency of late potentials (LPs) on signal averaged ECG (SAECG) and corrected QT dispersion (QTc-d) may improve prognosis of patients. In this study, the effect of metoprolol on frequency of LPs and QTc-d was investigated.

METHODS

Thirty-five patients (mean age 53 +/- 9 years) with acute myocardial infarction who were not given thrombolytic therapy were enrolled. Patients in whom metoprolol was not administered formed group I (n = 20) and patients who were given metoprolol constituted group II (n = 15). Metoprolol was administered as an initial dose of 15 mg intravenously, following 6-8 hours 100 mg/d orally. To determine the frequency of LPs, SAECG records were performed on admission and at the end of the first week. At the same time, resting ECG recordings (12 leads, 50 mm/s) were obtained to calculate QTc-d. Variance analysis was used for statistical analysis.

RESULTS

In group I; frequency of LPs were found 30% on admission and at the end of the first week. In group II; frequency of LPs were 6% on admission and at the end of the first week there was no LPs. There was no statistically significant difference between two groups according to TQRS, RMS-40, LAS40 and QTc-d

CONCLUSION

Metoprolol decreases the frequency of LPs. It has no effect on cQT-d.

[Ultrasonic integrated backscatter analysis in patients with dilated cardiomyopathy: comparison with healthy individuals]

OBJECTIVE

Ultrasonic tissue characterization, based on the measurements of integrated backscatter (IBS) analysis, has the potential to provide quantitative information which could characterize the functional and structural state of cardiac muscle. In this study we aimed to determine whether the integrated backscatter is measurable and quantifiable in left ventricular walls in patients with dilated cardiomyopathy (DCMP) and can be used to identify changes in myocardial structure and contractility.

METHODS

We studied 32 subjects: 16 patients with idiopathic dilated cardiomyopathy who were free of atrial fibrillation, bundle branch block and valvular heart disease (12 male, 4 female, mean age 48 +/- 18) and 16 healthy volunteers (10 male, 6 female, mean age 46 +/- 8). Left ventricular diastolic and systolic diameters, septum and posterior wall (PW) systolic and diastolic thickness were measured in the parasternal long axis view with M-mode echocardiography. Ejection fraction (EF), fractional shortening (FS), septum and posterior percent wall thickening (WT%) were calculated in the parasternal long axis view with M-mode echocardiography. Real time IBS was measured from the parasternal long axis view of the left ventricle at the level of basal posterior and septal walls. Mean IBS was expressed as averaged IBS values and cyclic variation of IBS (CVIBS) was expressed as the difference between end-diastolic (peak) and end-systolic (nadir) IBS values averaged over all cardiac cycles.

RESULTS

CVIBS values obtained from septum and PW in idiopathic DCMP group were statistically different from control group (p = 0.003, p < 0.001, respectively). Septal and PW mean IBS values in idiopathic DCMP group were greater and statistically different from control group (p < 0.05). Septum and PW CVIBS values correlated with WT%, EF and FS positively. But, septum and PW mean IBS values did not correlate with WT%, EF and FS.

CONCLUSION

CVIBS and mean IBS values which were obtained with IBS method may be useful to determine myocardial contractile performance and myocardial structural properties, respectively.

Myocardial infarction following a bee sting

We described here a patient envenomated by a bee sting that caused myocardial damage compatible with non-ST elevation acute myocardial infarction. She developed a typical course of myocardial infarction; the ECG changes were reversed to almost all normal limits. She had normal coronary angiography and reversible wall motion abnormalities. Myocardial damage following prolonged spasm in the coronary arteries may be the underlying factor.

Pseudoaneurysms of Bilateral Popliteal Arteries following Infective Endocarditis

A rare complication of infective endocarditis is pseudoaneurysm of the arterial wall. Aneurysms arise either from occlusion of vessels by septic emboli with secondary arteritis and vessel wall destruction or from bacteremic seeding of the vessel wall through the vasa vasorum. This paper reports on what the authors believe to be the first case of endocarditis presenting as pseudoaneurysm of the bilateral popliteal arteries.